In an August 21st meeting with CMS, staff shared with LeadingAge staff that they are working on drafting sub-regulatory guidance that would provide further clarifications to the recently finalized Medicare Advantage rules that largely take effect January 1, 2024. It sounds like the focus of this guidance will be on providing more specifics about which Medicare coverage regulations and guidance plans must follow and in what cases plans can deviate from their own internal criteria.
Another area they are looking closely at is how plans are using third-party algorithms or tools to determine the amount of care a person receives from a given provider. In this case, sub-regulatory guidance might clarify what steps a plan must take if they are planning to terminate service based upon the output of such a tool. For example, would the plan need to identify what coverage criteria are no longer being met resulting in the service termination? Would the plan need to conduct another assessment of the person’s current condition?
LeadingAge has been discussing these issues and others with other post-acute care associations to provide additional input into the CMS process. Members are encouraged to submit examples of non-compliance issues to Kylee Childs. What was the specific scenario where an MA plan made a decision that appeared not to comply with Medicare coverage criteria? What type of regulation, memo, etc. did the plan not follow (e.g., person showed lack of progress in rehabilitation but still had a feeding tube)? Or situations where a plan has stuck with the third-party care manager’s (e.g., NaviHealth, Care Centrix, MyNexxus) algorithm even though assessments or other information would suggest the person still has a skilled need. This information will be shared with CMS in aggregate to help guide the clarifications included in its sub-regulatory guidance.
